NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 651:

  A pregnant client experiences spontaneous rupture of membranes. The first nursing action is to:

  A. Assess the client's respirations

  B. Notify the physician

  C. Auscultate fetal heart rate

  D. Transfer to delivery suite

  Correct Answer: C

  (A) Immediately following membrane rupture, the fetus is at risk for complications, not necessarily the mother. (B) The physician is notified after the nurse completes an assessment of the mother's and fetus's conditions. (C) Rupture of membranes facilitates fetal descent. A potential complication is cord prolapse, which is assessed by auscultating fetal heart rate. (D) Rupture of membranes does not necessarily indicate readiness to deliver.

• Question 652:

  A 2-month-old infant is receiving IV fluids with a volume control set. The nurse uses this type of tubing because it:

  A. Prevents administration of other drugs

  B. Prevents entry of air into tubing

  C. Prevents inadvertent administration of a large amount of fluids

  D. Prevents phlebitis

  Correct Answer: C

  (A) A volume control set has a chamber that permits the administration of compatible drugs. (B) Air may enter a volume control set when tubing is not adequately purged. (C) A volume control set allows the nurse to control the amount of fluid administered over a set period. (D) Contamination of volume control set may cause phlebitis.

• Question 653:

  A client has been in labor for 10 hours. Her contractions have become hypoactive and slowed in duration. The fetus is at 0 station, cervix is dilated 8 cm and effaced 90%. The physician orders an oxytocin (Pitocin) infusion to be started at once. The RN begins the oxytocin infusion. It is important that the RN discontinue the infusion if which one of the following occur?

  A. The client's contractions are <2 minutes apart.

  B. Duration of the contractions are 60 seconds.

  C. The uterus relaxes between contractions.

  D. The client complains that she is tired.

  Correct Answer: A

  (A) It is very important that there is a resting phase or relaxation period between the contractions. During this period, the uterus, placenta, and umbilical vessels re-establish blood flow. No resting phase between contractions can lead to fetal bradycardia, fetal hypoxia, and acidosis. It can also result in a tetanic contraction, which can cause uterine rupture. (B) The goal of the oxytocin infusion is to help establish a contraction pattern lasting 45?0 seconds occurring every 2 minutes and a uterine tonus of 60?0 mm Hg. (C) This choice is correct. The uterus has time to recover from the contraction. (D) The client's tiring is no indication to stop the infusion. She will be tired even without the infusion.

• Question 654:

  A mother who is breast-feeding her newborn asks the RN, "How can I express milk from my breasts manually?" The RN tells her that the correct method for manual milk expression includes using the thumb and the index finger to: A. Alternately compress and release each nipple

  B. Roll the nipple and gently pull the nipple forward

  C. Slide the thumb and index finger forward from the outer border of the areola toward the end of the nipple

  D. Compress and release each breast at the outer border of the areola

  Correct Answer: D

  (A) Manipulation of nipples will cause soreness and trauma. (B) Pulling the nipples will cause discomfort and soreness. (C) Sliding the thumb and index finger forward over the nipple will cause soreness. (D) The best method to express milk from the breast is to position the thumb and index finger at the outer border of the areola and compress. This is the location of the milk sinuses.

• Question 655:

  A pregnant client continues to visit the clinic regularly during her pregnancy. During one of her visits while lying supine on the examining table, she tells the RN that she is becoming light-headed. The RN notices that the client has pallor in her face and is perspiring profusely.

  The first intervention the RN should initiate is to:

  A. Place the examining table in the Trendelenburg position

  B. Assess the client to see if she is having vaginal bleeding

  C. Obtain the client's vital signs immediately

  D. Help the client to a sitting position

  Correct Answer: D

  (A) This position would cause the gravid uterus to bear the increased pressure of the vena cava, which could lead to maternal hypotension, in turn causing the client to continue to have pallor and to feel light-headed. (B) This would not be the first intervention the RN should initiate. TheRN should understand the supine position and its effect on the gravid uterus and vena cava. (C) The RN's first intervention should be one that helps to alleviate the client's symptoms. Obtaining her vital signs will not alleviate her symptoms. (D) This would move the gravid uterus off of the client's vena cava, which would alleviate the maternal hypotension that is the cause of her symptoms.

• Question 656:

  The nurse working with a client who is out of control should follow a model of intervention that includes which of the following?

  A. Approach the client on a continuum of least restrictive care.

  B. Challenge client's behavior immediately with steps to prevent injury to self or others.

  C. Leave the aggressive client to himself or herself, and take other clients away.

  D. To ensure safety of other clients, place client in seclusion immediately when he or she begins shouting.

  Correct Answer: A

  (A) Approaching a client's aggressive behavior on a continuum of least restrictive care is in agreement with his or her rights (i.e., verbal methods to help maintain control, medication, seclusion, and restraints, as necessary). (B) Approaching a client in a challenging manner is threatening and inappropriate. A nonchallenging and calm approach reflects staff in control and may increase client's internal control. (C) It is inappropriate to leave an aggressive client who is acting out alone. The nurse should acquire qualified help to prevent client from harm or injury to self or others. (D) Moving a client to seclusion immediately for shouting is inappropriate. The nurse should offer the client an opportunity to control self with limit setting. The client should understand that the staff will assist with control if necessary (i.e., quietly accompany out of environment to decrease stimulation and allow for verbalization) employing the least restrictive care model of intervention.

• Question 657:

  A primigravida is at term. The nurse can recognize the second stage of labor by the client's desire to:

  A. Push during contractions

  B. Hyperventilate during contractions

  C. Walk between contractions

  D. Relax during contractions

  Correct Answer: A

  (A) The second stage of labor is characterized by uterine contractions, which cause the client to bear down. (B) Slow, deep, rhythmic breathing facilitates the laboring process. Hyperventilation is abnormal breathing resulting from loss of pain control. (C) The client should remain on bed rest during labor. (D) Contractions result in discomfort.

• Question 658:

  A client presents to the psychiatric unit crying hysterically. She is diagnosed with severe anxiety disorder. The first nursing action is to:

  A. Demand that she relax

  B. Ask what is the problem

  C. Stand or sit next to her

  D. Give her something to do

  Correct Answer: C

  (A) This nursing action is too controlling and authoritative. It could increase the client's anxiety level. (B) In her anxiety state, the client cannot rationally identify a problem. (C) This nursing action conveys a message of caring and security. (D) Giving the client a task would increase her anxiety. This would be a late nursing action.

• Question 659:

  A 35-year-old client is admitted to the hospital with diabetic ketoacidosis. Results of arterial blood gases are pH 7.2, PaO2 90, PaCO2 45, and HCO3 16. The nursing assessment of arterial blood gases indicate the presence of:

  A. Respiratory alkalosis

  B. Respiratory acidosis

  C. Metabolic alkalosis

  D. Metabolic acidosis

  Correct Answer: D

  (A) Respiratory alkalosis is determined by elevated pH and low PaCO2. (B) Respiratory acidosis is determined by low pH and elevated PaCO2. (C) Metabolic alkalosis is determined by elevated pH and HCO3.(D) Metabolic acidosis is determined by low pH and HCO3.

• Question 660:

  A premature infant needs supplemental O2 therapy. A nursing intervention that reduces the risk of retrolental fibroplasia is to:

  A. Maintain O2at <40%

  B. Maintain O2at>40%

  C. Give moist O2at>40%

  D. Maintain on 100% O2

  Correct Answer: A

  (A) Retrolental fibroplasia is the result of prolonged exposure to high levels of O2in premature infants. Complications are hemorrhage and retinal detachment. (B, C, D) O2concentration is too high.